Why some Rio Grande Valley doctors may no longer get paid for virtual visits

Over the last five years, Dr. Chris Casso has seen more patients in the Rio Grande Valley show up for their medical appointments when they don’t have to visit in person, but can instead join remotely via a phone or video call. 

“It really did improve some continuity of care, increased access to care, especially for patients that have difficulty getting to the doctor, they don’t have transportation, they’re older, they have mobility problems,” said Casso, a family medicine physician who works for a South Texas Health System clinic in McAllen. 

Before the COVID-19 pandemic began in March 2020, very few patients would even ask for a telemedicine visit; it was only those with severely debilitating diseases who would use a phone system, she said. 

But during COVID-19, about 4.5 million Texans used telemedicine for the first time, according to a 2020 survey conducted by the global consulting business Accenture. 

And the habit stuck. 

Healthcare providers told the Rio Grande Valley Business Journal that patients were seeing doctors more frequently, managing chronic conditions, opting for preventative care, and canceling appointments less often. 

“We were seeing more patients for preventative visits, screening exams, and their vaccinations,” Casso said. “Telehealth did improve access to professionals, and teachers, people who don’t have that ability to get out [in person].”

Telemedicine is caught in the middle

But since the federal government shutdown began on Oct. 1, doctors are not getting reimbursed for telemedicine visits with Medicare patients, because the COVID-19 era waiver expired on Sept. 30. 

Medicare typically covers individuals 65 years of age or older and is coordinated by the federal government. The waiver expiration, coupled with the government shutdown, could have affected 4.7 million Medicare enrollees across Texas. About half of them have traditional Medicare plans, and the remainder have Medicare Advantage plans. 

Across Rio Grande Valley clinics for one health system, about 20% of patients are no longer keeping regular doctor appointments because telemedicine may not be covered by their insurance, Casso said. 

Doctors are typically reimbursed for the type of care and corresponding procedure code, which does not distinguish between virtual or in-person visits so there’s no difference in price. 

“Our hope was that there was going to be a legislative bill that was going to extend this. And of course, with the government shut down, that has not happened. So we’re having to basically tell our patients, Medicare does not cover this anymore,” she said. “This is going to put a financial burden on them, which they already don’t need. We’re seeing higher no-show rates, and this is going to probably lead to more ER visits because they’re going to try to go somewhere where it’s closer to them.” 

It can be difficult to estimate how many patients are affected because many private insurers still cover telemedicine, but all the individual plan coverages change frequently. 

Health insurance may not cover phone visits 

“A lot of times, whatever CMS [Centers for Medicare & Medicaid Services] does [pay], private insurance will do. I know some of the Medicare Advantage programs are still trying to cover telehealth visits, but it’s individual plans, so it’s trying to figure out which one does and doesn’t,” Casso said. 

Then there’s the changing landscape for Medicaid, which is meant for low-income or disabled individuals and often covers children. Medicaid is coordinated on a statewide scale, so Texas creates its own rules for reimbursement to providers. 

“In the past year, Medicaid started saying no for some of these telehealth visits, so we could still do audio-video [over the phone], but if it was just phone, they were not allowing that,” Casso, the McAllen doctor, said. “That became an issue with Medicaid as well; we have to make sure that they have video capability to be able to get paid for that service.” 

For Dr. Diana Chapa, chair of the neuro and behavioral health department at the University of Texas at Rio Grande Valley and a board-certified psychiatrist, there is less disruption because there is still a carve-out for mental health services. 

“Now mental health, psychiatry is in a little bit better situation because we continue to get that exempt status where therapists can continue to provide tele [medicine], but how that is going to be compensated is something we’re going to have to keep a close eye on,” she said. 

But those reimbursements don’t always cover everything. 

During the state of emergency of the COVID-19 pandemic, insurance was required to reimburse providers at the same rate as in-person visits. Since then, in Texas, insurance is not allowed to deny claims for the sole reason that it’s telemedicine compared to in-person visits. But there are loopholes. 

“It’s concerning to all of us because we’re already seeing changes in the reimbursement. If you’re doing [a] telemedicine visit, some insurances don’t pay for facility fees,” Chapa said. “We’re in the middle of really trying to see where things are going to definitively end.”

How rural clinics rely on telemedicine

In rural communities, telemedicine has been a lifeline, even before the COVID-19 pandemic. 

“The only way that our clients can see psychiatrists is through telemedicine,” Maria Sanchez, chief executive officer at Border Region Behavioral Health Center, said during a recent hopistal stakeholder meeting in Starr County. 

Doctors hired by the nonprofit who live nationwide see mental health patients in counties including Starr, Zapata, Webb, and Jim Hogg – but it’s expensive, Sanchez said. 

For example, the Border Regional Behavioral Health Center paid three different telemedicine service providers a total of $3.2 million in 2023 alone, according to the nonprofit’s financial records. The most frequently used provider was Irving, Texas-based Consilium Staffing Inc., which received $1.8 million. 

Yadira Barrera is a physician’s assistant in Roma, which sits on the western edge of Starr County. Barrera is on the Roma Independent School District board and primarily practices pediatric medicine. 

She asked state officials during a recent public meeting to include telemedicine in a recent application for a new federal rural transformation fund. 

There’s a push for projects leveraging artificial intelligence in telemedicine to improve healthcare. But there are many things the grant would not cover – from new facility construction to transportation for patients to access care. 

“If we can’t advocate for transportation services, at least we can advocate for telehealth services,” Barrera said. “As far as pediatrics, it closes the gap because one – we can keep kids at school, we don’t have to tell them, get out of school so that they can get services. Sometimes parents work, they don’t take their kids to get [healthcare] services, or they don’t get the follow-up.”